Gallstones and Gallbladder Disease - Lithotripsy and Dissolution Therapies

Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy)

Laparoscopic Exploration and Cholangiography

Surgeons are now increasingly using laparoscopy with cholangiography instead of ERCP when common duct stones are suspected. Laparoscopy with cholangiography should only be done in centers with expertise in this procedure. This procedure should be done for the following reasons:

• As an alternative to ERCP before gallbladder surgeries, when there is a high suspicion of common bile duct stones.
• During gallbladder surgeries when common duct stones are detected or highly suspected.

The procedure usually involves the following steps:

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• The initial approach is the same as with laparoscopic cholecystectomy. One or two 10 - 12 mm (around half an inch) incisions and three 5 mm (about a fifth of an inch) incisions are made in the abdomen.
• A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiography.
• If stones are identified, the surgeon inserts a tube with an inflatable balloon to widen the duct.
• Stones are usually retrieved or withdrawn from the duct with either a balloon or tiny basket.
• If laparoscopy is unsuccessful, ERCP or open surgery is performed.

Experts are debating whether this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice of treatment. Still, laparoscopy for common duct stones should be performed only by experienced surgeons.

Open Common Bile Duct Exploration (Choledocholithotomy)

Choledocholithotomy, or common bile duct exploration, is used:

• To remove large stones
• When the duct anatomy is complex
• During or after some gallbladder operations when stones are detected. If the procedure is being performed laparoscopically, the surgeon may convert to an open procedure, though this happens less often now.
• When ERCP or laparoscopic procedures are not available.

In this procedure, the doctor performs open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a "T-tube" is temporarily left in the common bile duct after surgery and the doctor x-rays the bile duct through the tube 7 - 10 days after surgery, to determine whether any stones remain in the duct.

Review Date: 06/10/2010
Reviewed By: Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).